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van Olst N, Vink MRA, de Vet SCP, Hutten BA, Gerdes VEA, Tielbeek JAW, Bruin SC, van Weyenberg SJB, van der Peet DL, Acherman YIZ. A Prospective Study on the Diagnoses for Abdominal Pain After Bariatric Surgery: The OPERATE Study. Obes Surg 2023; 33:3017-3027. [PMID: 37563516 PMCID: PMC10514148 DOI: 10.1007/s11695-023-06756-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/06/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Long-term follow-up after bariatric surgery (BS) reveals high numbers of patients with abdominal pain that often remains unexplained. The aim of this prospective study was to give an overview of diagnoses for abdominal pain, percentage of unexplained complaints, number and yield of follow-up visits, and time to establish a diagnosis. MATERIALS AND METHODS Patients who visited the Spaarne Gasthuis Hospital, The Netherlands, between December 2020 and December 2021 for abdominal pain after BS, were eligible and followed throughout the entire episode of abdominal pain. Distinction was made between presumed and definitive diagnoses. RESULTS The study comprised 441 patients with abdominal pain; 401 (90.9%) females, 380 (87.7%) had Roux-en-Y gastric bypass, mean (SD) % total weight loss was 31.4 (10.5), and median (IQR) time after BS was 37.0 (11.0-66.0) months. Most patients had 1-5 follow-up visits. Readmissions and reoperations were present in 212 (48.1%) and 164 (37.2%) patients. At the end of the episode, 88 (20.0%) patients had a presumed diagnosis, 183 (41.5%) a definitive diagnosis, and 170 (38.5%) unexplained complaints. Most common definitive diagnoses were cholelithiasis, ulcers, internal herniations, and presumed diagnoses irritable bowel syndrome (IBS), anterior cutaneous nerve entrapment syndrome, and constipation. Median (IQR) time to presumed diagnoses, definitive diagnoses, or unexplained complaints was 16.0 (3.8-44.5), 2.0 (0.0-31.5), and 13.5 (1.0-53.8) days (p < 0.001). Patients with IBS more often had unexplained complaints (OR 95%CI: 4.457 [1.455-13.654], p = 0.009). At the end, 71 patients (16.1%) still experienced abdominal pain. CONCLUSION Over a third of abdominal complaints after BS remains unexplained. Most common diagnoses were cholelithiasis, ulcers, and internal herniations.
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Affiliation(s)
- Nienke van Olst
- Department of Bariatric Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands.
- Department of Surgery, Amsterdam UMC, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Marjolein R A Vink
- Department of Bariatric Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Sterre C P de Vet
- Department of Bariatric Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Barbara A Hutten
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Victor E A Gerdes
- Department of Bariatric Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
- Department of Vascular Medicine Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeroen A W Tielbeek
- Department of Radiology, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Sjoerd C Bruin
- Department of Bariatric Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Stijn J B van Weyenberg
- Department of Gastroenterology, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Yair I Z Acherman
- Department of Bariatric Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
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Zaigham H, Ekelund M, Regnér S. Long-Term Follow-up and Risk of Recurrence of Internal Herniation after Roux-en-Y Gastric Bypass. Obes Surg 2023; 33:2311-2316. [PMID: 37266865 PMCID: PMC10344975 DOI: 10.1007/s11695-023-06653-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE Internal herniation (IH) is the most common complication after Roux-en-Y gastric bypass surgery (RYGB). Although primary closure has reduced the incidence, recurrences are a continued problem. This study aimed to investigate long-term follow-up and recurrence risk of IH surgery. METHODS A retrospective cohort study of laparoscopic RYGB operated patients operated for a first IH between April 2012 and April 2015 at Skåne University Hospital in Malmö, Sweden. Status of primary closure of mesenteric gaps, time since RYGB, and findings at IH surgery were retrieved from medical records. Follow-up until December 31st, 2019, included recurrences of IH, number of computed tomography (CT) scans, emergency visits, readmissions, and other acute surgeries. RESULTS IH (n = 44) occurred almost equally in Petersen's space (n = 24) and beneath the jejunojejunostomy (n = 20). Long-term follow-up (median 75 months) of 43 patients registered an IH recurrence rate of 14% (n = 6). All recurrences occurred in the other mesenteric gap. One patient suffered a third IH, and one patient had four IH events. During follow-up, 56% (n = 24) had ER visits for abdominal pain, 47% (n = 20) had ≥ 1 abdominal CT scan, and 40% (n = 17) were readmitted. A third of readmitted (6/17) patients suffered a recurrence of internal herniation. Two other patients were readmitted ≥ 10 times for chronic abdominal pain. CONCLUSION Surgery for IH had a low risk of recurrence at the treated mesenteric gap, but a 14% recurrence risk at the other mesenteric gap, emphasizing the importance of carefully investigating weaknesses or gaps at the other mesenteric defect during surgery for IH.
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Affiliation(s)
- Hassan Zaigham
- Surgery Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
- Department of Surgery and Gastroenterology, Skåne University Hospital, Malmö, Sweden.
| | - Mikael Ekelund
- Surgery Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Surgery and Gastroenterology, Skåne University Hospital, Malmö, Sweden
| | - Sara Regnér
- Surgery Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Surgery and Gastroenterology, Skåne University Hospital, Malmö, Sweden
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Clapp B. Reply to Schlottmann et al. Surg Obes Relat Dis 2023; 19:535. [PMID: 36918325 DOI: 10.1016/j.soard.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/08/2023]
Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
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Zaigham H, Ekelund M, Lee D, Ekberg O, Regnér S. Intussusception After Roux-en-Y Gastric Bypass: Correlation Between Radiological and Operative Findings. Obes Surg 2023; 33:475-481. [PMID: 36474098 PMCID: PMC9889503 DOI: 10.1007/s11695-022-06377-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/20/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Intussusceptions diagnosed on computed tomography (CT) scans in Roux-en-Y gastric bypass (RYGB) patients could cause serious small bowel obstruction (SBO) or be an incidental finding. The objective of this study was to correlate radiological findings with clinical outcomes to differentiate intussusceptions requiring emergent surgery for SBO. METHODS A search for acute abdominal CT scans reporting intussusceptions in RYGB patients between 2012 and 2019 at Skåne University Hospital, Malmö, Sweden, retrieved 35 scans. These were independently reevaluated by two radiologists for the length and location of the intussusception, whether oral contrast passed through, proximal bowel dilatation, and signs of internal herniation. Clinical outcome in terms of emergency surgery and the diagnosis was determined through chart review. RESULTS Out of 35 acute patients, 9 patients required emergency surgery within 24 h. Intussusception caused SBO in five patients, and one patient had an internal herniation, while three patients had unremarkable findings. Eight patients were evaluated for intermittent pain with five unremarkable laparoscopies, while 18 patients had intussusceptions as incidental findings. Intussusception length on CT as measured by radiologists O.E. and D.L. predicted acute bowel obstruction (p = .014 and p < .001). A 100 mm threshold predicted bowel obstruction with a sensitivity of 80% and 100% and a specificity of 93% and 86% by radiologists O.E. and D.L., respectively. Proximal bowel dilatation predicted SBOs of any cause as well as SBO caused by an intussusception (all p < .05). CONCLUSION Intussusception length > 100 mm on CT in RYGB patients is an easy and valuable sign indicating SBO that may require emergent surgery.
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Affiliation(s)
- Hassan Zaigham
- Department of Clinical Sciences, Malmö, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Mikael Ekelund
- Department of Clinical Sciences, Malmö, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Daisy Lee
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Sara Regnér
- Department of Clinical Sciences, Malmö, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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Toneman MK, de Kok BM, Zijta FM, Oei S, van Acker GJD, Westerterp M, van der Pool AEM. Predicting the outcome of closed-loop small bowel obstruction by preoperative characteristics. World J Gastrointest Surg 2022; 14:556-566. [PMID: 35979424 PMCID: PMC9258239 DOI: 10.4240/wjgs.v14.i6.556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/24/2021] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Closed-loop small bowel obstruction (CL-SBO) can threaten the viability of the intestine by obstructing a bowel segment at two adjacent points. Prompt recognition and surgery are crucial.
AIM To analyze the outcomes of patients who underwent surgery for CL-SBO and to evaluate clinical predictors.
METHODS Patients who underwent surgery for suspected CL-BSO on computed tomography (CT) at a single center between 2013 and 2019 were evaluated retrospectively. Patients were divided into three groups by perioperative outcome, including viable bowel, reversible ischemia, and irreversible ischemia. Clinical and laboratorial variables at presentation were compared and postoperative outcomes were analyzed.
RESULTS Of 148 patients with CL-SBO, 28 (19%) had a perioperative viable small bowel, 86 (58%) had reversible ischemia, and 34 (23%) had irreversible ischemia. Patients with a higher age had higher risk for perioperative irreversible ischemia [odds ratio (OR): 1.03, 95% confidence interval (CI): 0.99-1.06]. Patients with American Society of Anaesthesiologists (ASA) classification ≥ 3 had higher risk of perioperative irreversible ischemia compared to lower ASA classifications (OR: 3.76, 95%CI: 1.31-10.81). Eighty-six patients (58%) did not have elevated C-reactive protein (> 10 mg/L), and between-group differences were insignificant. Postoperative in-hospital stay was significantly longer for patients with irreversible ischemia (median 8 d, P = 0.001) than for those with reversible ischemia (median 6 d) or a viable bowel (median 5 d). Postoperative morbidity was significantly higher in patients with perioperative irreversible ischemia (45%, P = 0.043) compared with reversible ischemia (20%) and viable bowel (4%).
CONCLUSION Older patients or those with higher ASA classification had an increased risk of irreversible ischemia in case of CL-SBO. After irreversible ischemia, postoperative morbidity was increased.
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Affiliation(s)
- Masja K Toneman
- Department of Surgery, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Bente M de Kok
- Department of Radiology, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Frank M Zijta
- Department of Radiology, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Stanley Oei
- Department of Radiology, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Gijs J D van Acker
- Department of Surgery, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Marinke Westerterp
- Department of Surgery, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
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The Diagnostic Accuracy of Abdominal Computed Tomography in Diagnosing Internal Herniation Following Roux-en-Y Gastric Bypass Surgery: A Systematic Review and Meta-analysis. Ann Surg 2022; 275:856-863. [PMID: 35129527 DOI: 10.1097/sla.0000000000005247] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyze the diagnostic accuracy of abdominal computed tomography (CT) in diagnosing internal herniation (IH) following Rouxen-Y gastric bypass (RYGB) surgery. SUMMARY OF BACKGROUND DATA IH is one of the most important and challenging complications following RYGB. Therefore, early and adequate diagnosis of IH is necessary. Currently, exploratory surgery is considered the gold standard in diagnosing IH. Although CT scans are frequently being used, the true diagnostic accuracy in diagnosing IH remains unclear. METHODS PubMed, Embase, and Cochrane databases were systematically searched for relevant articles describing the diagnostic accuracy of abdominal CT in diagnosing IH after RYGB. Data were extracted, recalculated, and pooled to report on the overall diagnostic accuracy of CT in diagnosing IH, and the diagnostic accuracy of specific radiological signs. RESULTS A total of 20 studies describing 1637 patients were included. seventeen studies provided data regarding the overall diagnostic accuracy: pooled sensitivity of 82.0%, specificity of 84.8%, positive predictive value of 82.7%, and negative predictive value of 85.8% were calculated. Eleven studies reported on specific CT signs and their diagnostic accuracy. The radiological signs with the highest sensitivity were the signs of venous congestion, swirl, and mesenteric oedema (sensitivity of 78.7%, 77.8%, and 67.2%, respectively). CONCLUSIONS This meta-analysis demonstrates that CT is a reliable imaging modality for the detection of IH. Therefore, abdominal CT imaging should be added to the diagnostic work-up for RYGB patients who present themselves with abdominal pain suggestive of IH to improve patient selection for explorative surgery.
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Mala T, Chahal-Kummen M, Kristinsson J. Letter to the Editor. Obes Surg 2021; 31:5459. [PMID: 34165667 DOI: 10.1007/s11695-021-05523-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Tom Mala
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Pb, 4950 0424, Oslo, Norway.
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Pb, 4950 0424, Oslo, Norway.
- Institute of Clinical Medicine, The University of Oslo, Oslo, Norway.
| | - Monica Chahal-Kummen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Pb, 4950 0424, Oslo, Norway
- Institute of Clinical Medicine, The University of Oslo, Oslo, Norway
| | - Jon Kristinsson
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Pb, 4950 0424, Oslo, Norway
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Clapp B, Grasso S, Harper B, Amin MA, Kim J, Davis B. 5-year follow-up at an accredited community bariatric practice: what is an acceptable follow-up rate? Surg Obes Relat Dis 2021; 18:505-510. [DOI: 10.1016/j.soard.2021.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 11/20/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
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Clapp B, Wicker E, Vivar A, Kara AM, Gamez J, Davis B. Long Term Outcomes after Laparoscopic Assisted Trans-Gastric Endoscopic Retrograde Cholangiopancreatography. JSLS 2021; 25:JSLS.2021.00048. [PMID: 34552319 PMCID: PMC8443239 DOI: 10.4293/jsls.2021.00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: The gastric bypass is a commonly performed bariatric procedure. The stomach is divided into a small pouch as well as leaving a larger remnant that is bypassed by the gastrojejunal anastomosis. This makes access to the biliary system difficult as an endoscope cannot transverse the esophagus, roux limb, and biliopancreatic limb. Therefore, a transgastric approach (endoscopic retrograde cholangiopancreatography [t-ERCP]) through the abdominal wall and remnant stomach is necessary. This involves the surgical team providing access to the remnant stomach for the gastroenterologist to perform the t-ERCP. We have performed a number of these for biliary pathology that ranges from cancer to retained gallstones. We evaluated these patients with at least a 3-year follow-up to determine long term outcomes. Methods: We conducted a chart review of patients who underwent a t-ERCP with at least a 3-year follow-up. We collected de-identified data including demographics, operative details, complications, and postoperative courses. Results: There were 12 patients who underwent t-ERCP. Eleven patients had at least a 3-year follow-up with a mean follow-up of 68.1 months (excluding one death from pancreatic cancer). The most common pathology was benign biliary stricture (n = 6), followed by retained gallstones (n = 4), with one pancreatic cancer, and one normal examination. Two patients still had epigastric pain at long term follow-up after 3 years. Conclusion: T-ERCP is safe and efficacious with good long-term results.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Ellen Wicker
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Andres Vivar
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Ali M Kara
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Jesus Gamez
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Brian Davis
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
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Zaigham H, Olsson Regnér Å, Ekelund M, Regnér S. The role of citrulline, intestinal fatty acid-binding protein, and D-dimer as potential biomarkers in the diagnosis of internal herniation after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2021; 17:1704-1712. [PMID: 34167910 DOI: 10.1016/j.soard.2021.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/21/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Diagnosing internal herniation (IH) in Roux-en-Y gastric bypass (RYGB) patients with acute abdominal pain poses a diagnostic challenge. Diagnostic laparoscopy is often required for a definitive diagnosis. We hypothesized that intestinal ischemia biomarkers would aid in the diagnosing of IH. OBJECTIVES To explore intestinal ischemia biomarkers in diagnosing IH. SETTING University Hospital, Sweden. METHODS Prospective inclusion of 46 RYGB patients admitted for acute abdominal pain between June 2015 and December 2017. Blood samples for analysis of citrulline, intestinal fatty acid-binding protein (I-FABP), and D-dimer were drawn <72 hours from admission and compared between patients with IH (n = 8), small bowel obstruction (SBO) (n = 5), other specified diagnoses (n = 12), or unspecified abdominal pain (n = 21). Levels of white blood cell count (WBC), C-reactive protein (CRP), and lactate at admission were compared. A prospective pain questionnaire for time of pain onset and level of pain at onset and at admission was analyzed. RESULTS None of the investigated biomarkers differed significantly between diagnosis categories. Most patients with IH had normal CRP, WBC, and D-dimer levels while their lactate levels were significantly lower (P = .029) compared with the rest of the cohort. Neither pain level nor pain duration differed between the groups. CONCLUSION This study shows that citrulline, I-FABP, and D-dimer cannot be used to diagnose IH and indicates that CRP, D-dimer, and lactate are rarely elevated by an IH. Furthermore, pain intensity and duration cannot differentiate patients with IH. A diagnostic laparoscopy remains the gold standard to diagnose and rule out an IH.
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Affiliation(s)
- Hassan Zaigham
- Department of Clinical Sciences, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Åsa Olsson Regnér
- Department of Clinical Sciences, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Mikael Ekelund
- Department of Clinical Sciences, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Sara Regnér
- Department of Clinical Sciences, Section of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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